U.S. patent number 5,643,282 [Application Number 08/293,855] was granted by the patent office on 1997-07-01 for surgical instrument and method for removing tissue from an endoscopic workspace.
Invention is credited to Maciej J. Kieturakis.
United States Patent |
5,643,282 |
Kieturakis |
July 1, 1997 |
Surgical instrument and method for removing tissue from an
endoscopic workspace
Abstract
A surgical instrument is used to remove excised tissue from an
insufflated anatomic cavity through a body wall overlying an
endoscopic workspace. The instrument includes an elongate tubular
sleeve defining an interior bore fore removing a tissue. The
tubular sleeve also called a snake is elastic in its transverse
sectional dimension so that the interior bore can expand to
accommodate the excise tissue as it is slidably withdrawn through
the bore. The sleeve is not elastic in the longitudinal direction
due to flexible but non-elastic longitudinal elements integrated
into or on the wall of the sleeve.
Inventors: |
Kieturakis; Maciej J. (San
Carlos, CA) |
Family
ID: |
23130876 |
Appl.
No.: |
08/293,855 |
Filed: |
August 22, 1994 |
Current U.S.
Class: |
606/114;
606/127 |
Current CPC
Class: |
A61B
17/3431 (20130101); A61B 17/3439 (20130101); A61B
2017/00287 (20130101); A61B 90/40 (20160201) |
Current International
Class: |
A61B
17/34 (20060101); A61B 19/00 (20060101); A61B
17/00 (20060101); A61B 017/24 () |
Field of
Search: |
;606/114,127,170,171,205
;403/292,321,DIG.8 ;604/133 |
References Cited
[Referenced By]
U.S. Patent Documents
Primary Examiner: Brown; Michael A.
Attorney, Agent or Firm: Skjerven, Morrill, MacPherson,
Franklin & Friel Klivans; Norman R.
Claims
I claim:
1. An instrument for removing excised tissue from the interior of a
body through an incision for a cannula and for guiding a cannula
into and of said incision, comprising:
an elongate tubular sleeve having proximal and distal ends and a
medial portion, a sleeve wall defining an interior bore extending
therethrough;
an exterior of the tubular sleeve having a first repose position
with a first transverse dimension, at least a portion of said
tubular sleeve being capable of a second tensioned position with an
expanded second transverse dimension;
wherein at least a portion of said interior bore expands in its
transverse dimension when the tubular sleeve moves to said second
tensioned position from said first repose position to accommodate a
cross section of excised tissue pulled through said bore to a
location exterior of the body;
wherein the instrument with the tubular sleeve in the repose
position is capable of being passed through the bore of said
cannula thereby serving as a guide to introduce said cannula into
and out of said incision;
wherein said sleeve wall comprises a plurality of flexible elements
including a first set disposed in a right-hand helical
configuration and a second set disposed in a left-hand helical
configuration and said first and second sets are interwoven.
2. A surgical instrument for removal of excised tissue from an
endoscopic workspace, comprising:
an elongate sleeve having proximal and distal ends and a medial
portion, a sleeve wall defining an interior bore wherein said bore
expands and contracts in its transverse sectional dimension to
accommodate a cross section of excised tissue pulled through said
bore;
wherein said sleeve wall comprises a plurality of flexible elements
including a first set disposed in a right-hand helical
configuration and a second set disposed in a left-hand helical
configuration and said first and second sets are interwoven.
3. The instrument of claim 2 wherein said sleeve wall is an
elastomeric material.
4. The instrument of claim 2 wherein said sleeve wall is a
plurality of flexible stiffening elements.
5. The instrument of claim 4 wherein said plurality of flexible
elements are disposed longitudinally to said sleeve wall.
6. The instrument of claim 4 wherein said plurality of flexible
elements are disposed helically to said sleeve wall.
7. The instrument of claim 2 wherein said sleeve wall includes an
elastomeric component.
8. The instrument of claim 2 wherein said distal end of said
tubular sleeve has a flared shape in a first repose position and is
resiliently deformable to a cylindrical shape in a second tensioned
position.
9. The instrument of claim 8 wherein the flared shaped repose
position is induced by a plurality of resiliently formed flexible
elements included in said sleeve wall.
10. The instrument of claim 8 together with a constraining sleeve
slidably mounted around said tubular sleeve, wherein said flared
shape of said tubular sleeve is maintained in either said repose
position or said tensioned position by the slidable disposition of
said constraining sleeve.
11. The instrument of claim 2 wherein said tubular sleeve defines
at least one longitudinal slit in said tubular sleeve within said
medial portion of said tubular sleeve.
12. An instrument for removing excised tissue from the interior of
a body through an incision for a cannula and for guiding a cannula
into and of said incision, comprising:
an elongate tubular sleeve having proximal and distal ends and a
medial portion, a sleeve wall defining an interior bore extending
therethrough;
an exterior of the tubular sleeve having a first repose position
with a first transverse dimension, at least a portion of said
tubular sleeve being capable of a second tensioned position with an
expanded second transverse dimension;
wherein at least a portion of said interior bore expands in its
transverse dimension when the tubular sleeve moves to said second
tensioned position from said first repose position to accommodate a
cross section of excised tissue pulled through said bore to a
location exterior of the body;
wherein the instrument with the tubular sleeve in the repose
position is capable of being passed through the bore of said
cannula thereby serving as a guide to introduce said cannula into
and out of said incision; and
wherein said sleeve wall comprises a plurality of flexible elements
including a first set disposed in a right-hand helical
configuration and a second set disposed in a left-hand helical
configuration and said first and second sets are interwoven;
and further comprising:
an elongate inner sleeve slidably carried within said interior bore
of said tubular sleeve, the inner sleeve having a proximal end and
a distal portion with a second sleeve wall defining an interior
second bore extending therethrough, wherein at least the distal
portion of said second bore is capable of expansion in its
transverse sectional dimension to accommodate the cross section of
said excised tissue recovered within said second bore.
13. The instrument of claim 12 wherein said second bore in the
distal portion of said inner sleeve has an increasing transverse
sectional dimension in the distal direction in a repose position
and is resiliently deformable to a cylindrical shape in a tensioned
position.
14. The instrument of claim 13 wherein the distal portion of said
inner sleeve wall includes a plurality of flexible elements
including a first set disposed in a right-hand helical
configuration and a second set disposed in a left-hand helical
configuration, and said first and second sets are interwoven.
15. A method for removing excised tissue from the interior of the
body through a body wall wherein said excised tissue has a greater
transverse dimension than an incision for a cannula through said
body wall, utilizing an elongate tubular sleeve defining an
interior bore capable of repose and expanded positions, comprising
the steps of:
introducing a distal portion of said tubular sleeve through the
cannula disposed in said incision through said body wall;
withdrawing proximally the cannula from said incision over said
tubular sleeve, thereby leaving said tubular sleeve in said body
wall;
advancing a tissue-engaging instrument through said bore in said
tubular sleeve;
engaging the tissue with said instrument;
pulling the tissue proximally through said bore in said tubular
sleeve thereby causing said bore to expand in its transverse
sectional dimension to an expanded position to accommodate the
proximal movement of said excised tissue, thereby displacing tissue
in the body wall surrounding said tubular sleeve radially outward
to accommodate the proximal movement of said excised tissue;
and
re-introducing the cannula back into said incision over said
tubular sleeve thereby using said tubular sleeve as a guide for the
cannula.
16. The method of claim 15 wherein said tubular sleeve defines at
least one slit in a wall of its medial portion, further comprising
the step of removing said excised tissue from said bore through
said slit.
17. The method of claim 15 further comprising the step of removing
said excised tissue from said bore through a proximal end of said
bore.
18. The method of claim 15 wherein after said excised tissue has
been removed from said bore, further comprising the step of
withdrawing said tubular sleeve from said cannula.
19. A method for removing excised tissue from the interior of the
body, said excised tissue having a greater transverse dimension
than the incision providing access to the interior of the body
utilizing an instrument comprising an outer first sleeve and a
cooperating inner sleeve, wherein said outer and inner sleeves
define respective first and second interior bores, comprising the
steps of:
introducing a distal portion of the instrument through a cannula
disposed within a body wall into the interior of the body to the
location of said excised tissue;
positioning said excised tissue within the distal portion of said
second bore with an accessory instrument;
pulling the inner sleeve with said excised tissue disposed therein
proximally through the first bore;
causing said first and second bores to expand in their transverse
sectional dimension to accommodate the proximal movement of said
excised tissue, thereby displacing tissue in said body wall
surrounding said outer and inner sleeves radially outward to
accommodate the proximal movement of said excised tissue; and
reintroducing the cannula back into the incision over said outer
sleeve thereby using said outer sleeve as a guide and thereafter
withdrawing said outer sleeve from the cannula.
20. The method of claim 19, wherein said step of positioning
comprises:
sliding a tissue-engaging instrument distally through the second
bore; and
engaging and transporting said excised tissue into the distal
portion of said second bore.
21. The method of claim 19, wherein said step of positioning
comprises:
introducing an accessory instrument into the exterior of the body
through the cannula; and
pushing the excised tissue with the necessary instrument into the
distal portion of said second bore.
22. A surgical instrument for removal of excised tissue from an
interior of a body, comprising:
an elongate first sleeve having proximal and distal ends and a
medial portion, a sleeve wall defining an interior bore wherein
said bore expands and contracts in its transverse sectional
dimension to accommodate a cross section of excised tissue pulled
through said bore; and
an elongate inner sleeve dimensioned for slidable disposition
within said interior bore of said first sleeve, and having a
proximal lend and a distal portion, a second sleeve wall defining
an interior second bore extending therethrough, wherein the distal
portion of said second bore expands and contracts in its transverse
sectional dimension to accommodate the cross section of said
excised tissue recovered within said second bore;
wherein said interior second bore in the distal portion of said
inner sleeve has an increasing transverse sectional dimension in
the distal direction in a repose position and is resiliently
deformable to a cylindrical shape in a tensioned position.
Description
BACKGROUND OF THE INVENTION
1. Field of the Invention
This invention relates to surgical instrumentation and more
particularly to an instrument and method for removing excised
tissue from an insufflated endoscopic workspace in cases in which
such tissue has a larger transverse dimension than the incision
providing access to the workspace.
2. Description of Prior Art
In a "minimally invasive" endoscopic surgery in an insufflated
workspace, for example an insufflated abdominal cavity, it has been
found that it is sometimes difficult to remove excised tissue from
the workspace. Since instruments are introduced into the workspace
typically through 10 mm. diameter cannulas within the abdominal
wall, it may not be possible to drag tissue pieces much larger than
10 mm. in cross section through the cannula. The use of larger
diameter cannulas is possible but undesirable because of the larger
incisions required. Also, dragging tissue through a cannula
assembly often contaminates the cannula valve, preventing the valve
from sealing insufflation gases within the workspace. A
contaminated valve also may contaminate the lens of an endoscope
subsequently introduced through the cannula. There is therefore a
need for new instruments and methods for removing excised tissue
from an endoscopic workspace.
SUMMARY OF THE INVENTION
In general, the instrument and method of the present invention are
utilized to remove tissue from an insufflated anatomic cavity
though the body wall overlying the endoscopic workspace. The
instrument in accordance with the present invention includes an
elongate tubular sleeve defining an interior lumen (bore) for
removing tissue. The tubular sleeve or "snake" is elastic in
transverse sectional dimension so that the interior "snake lumen"
can expand to accommodate the excised tissue as it is slidably
withdrawn through the lumen. The tubular sleeve herein is called a
"snake" because it compares to the body of a snake that stretches
in transverse dimension to accommodate any large item that the
snake consumes. The snake in accordance with the invention is not
elastic in the longitudinal direction in some embodiments due to
flexible but non-elastic longitudinal elements integrated into or
on a surface of the wall of the snake.
In an exemplary method, assume that the surgeon wishes to remove an
excised lymph node from an insufflated workspace overlain by the
abdominal wall. Further assume that the insufflated workspace is
provided with standard 10 mm. cannulas and the excised tissue has a
cross sectional dimension of greater than 10 mm.
The surgeon introduces the snake though one of the cannulas into
the workspace. The rigid cannula is then slid outward over the
snake leaving only the expandable snake within the abdominal wall.
The surgeon then introduces an accessory grasping instrument (e.g.,
a grasper or snare) though the snake lumen into the workspace.
Under endoscopic vision, the surgeon grasps the tissue with the
grasper instrument and then draws the tissue outwardly through the
snake lumen. As the surgeon uses one hand to stabilize the snake,
the excised tissue causes the snake lumen to expand or swell in
transverse dimension as it passes through the lumen. As the excised
tissue is pulled through the snake into the abdominal wall, the
tissue layers in the abdominal wall are displaced radially outward
to accommodate the swelled region of the snake. After the excised
tissue is disposed outside the abdominal wall but still within the
snake lumen, the surgeon or an assistant uses another instrument
(e.g., a forceps) to remove the tissue from the lumen through a
longitudinal slit in the wall of the snake. Thereafter, the
grasping instrument in the snake lumen may be reintroduced into the
workspace to remove other pieces of tissue in a like manner.
Thereafter, the cannula then easily may be slid inwardly into its
original position in the abdominal wall with the snake serving as a
guide through the incision and the snake may be withdrawn from the
cannula.
In general, the present invention provides an instrument and method
for removing excised tissue from an insufflated workspace. The
present invention also provides an instrument and method for
removing excised tissue having a larger transverse dimension than
the bore of a cannula disposed within the body wall overlying the
workspace.
The present invention provides an instrument having an interior
lumen or passageway that is expandable in transverse dimension to
accommodate the cross-sectional dimension of excised tissue. The
present invention also provides an instrument and method for
removing tissue from a workspace through a small incision that
allows the resilience of tissue layers in the body wall to
accommodate the proximal movement of excised tissue by transitory
radial displacement of the tissue layers surrounding the incision
rather than by enlarging the incision.
The present invention provides an instrument and method for
removing excised tissue through a cannula without contaminating the
cannula valve. The present invention also provides an instrument
and method for removing tissue from the interior of the body
quickly and efficiently. The present invention also provides an
instrument and method that is compatible with existing endoscopic
instrumentation.
Additional advantages and features of the invention appear in the
following description in which several embodiments are set
forth.
BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 is an elevational view of a snake device of the present
invention including a snake sleeve and a constraining sleeve.
FIG. 2 is an elevational view similar to FIG. 1 with the
constraining sleeve in an alternative position.
FIG. 3 is an elevational view of the snake sleeve of FIG. 2 taken
along line 3--3 of FIG. 2 showing excised tissue disposed within
the lumen in the snake.
FIG. 4 is a transverse sectional view of the snake sleeve of FIG. 3
taken along line 4--4 of FIG. 3.
FIG. 5 is a transverse sectional view of the snake sleeve of FIG. 3
taken along line 5--5 of FIG. 3.
FIG. 6 is an axionometric view of the a portion of the snake device
of FIG. 1 taken from along line 6--6 of FIG. 1.
FIG. 7 is an axionometric view similar to FIG. 6 in an alternative
configuration.
FIGS. 8A-8H are sectional views of a patient's abdominal wall
illustrating the manner in which a method in accordance with the
present invention is practiced utilizing the instrument of FIG.
1.
FIG. 9 is an elevational view of an alternative embodiment of a
dual-sleeve snake.
FIG. 10 is an elevational view of the dual-sleeve snake of FIG. 9
in an alternative configuration.
FIGS. 11A-11H are sectional views of a patient's abdominal wall
illustrating the manner in which a method in accordance with the
present invention is practiced utilizing the instrument of FIG.
8.
FIGS. 12A-12B are enlarged views of a portion of an alternative
embodiment of a snake sleeve.
FIG. 13 is an elevational view of a portion of an alternative
embodiment of a snake sleeve.
FIG. 14 is an elevational view of the snake sleeve of FIG. 12 with
tissue disposed in the lumen of the snake.
FIG. 15 is an elevational view of an alternative embodiment of a
tissue recovery sleeve disposed within a snake sleeve.
FIGS. 16A-16B are sectional views of a patient's abdominal wall
illustrating the manner in which a method in accordance with the
present invention may be practiced utilizing the tissue-recovery
sleeve of FIG. 15 .
DETAILED DESCRIPTION OF THE INVENTION
By way of example, FIGS. 1 and 2 depict tissue-removing instrument
or snake 5 including snake sleeve 10 that is adapted for removing
excised tissue from an endoscopic workspace. Snake sleeve 10 with
proximal end 11, medial region 12 and distal end 14, is illustrated
in FIG. 1 prepared for introduction through a cannula. Snake sleeve
10 has a generally cylindrical shape along longitudinal axis 16
with an overall length of approximately 250 to 500 millimeters (not
limiting). The transverse sectional dimension of snake sleeve 10 in
a repose state is approximately 10 mm. for introduction through a
standard 10 to 11 mm. diameter cannula but such diameter may be any
suitable dimension to cooperate with other diameter cannulas.
Referring to FIGS. 3 and 4, snake sleeve 10 has an interior bore or
snake lumen 20 extending along axis 16. The wall 18 of snake sleeve
10 is made of elastomeric material such as latex thus making snake
lumen 20 capable of expanding in transverse dimension to
accommodate excised tissue 22 as it is pulled through the lumen
(see FIGS. 3 and 5). The wall 18 of snake sleeve 10 includes a
plurality of longitudinal stiffening elements 25 that may be
impregnated within wall 18 or fixed by any suitable means such as
adhesives to the inner surface 26 of wall 18 surrounding lumen 20
(see FIG. 4). The stiffeners 25 may be fabricated of any suitable
material such as plastic or metal that is not elastic
longitudinally but is capable of flexing radially outward from axis
16 as shown in FIG. 3.
The distal end 14 of snake sleeve 10 has a bell (flared) shape 27
that results from the distal ends of stiffeners 25 being
resiliently formed in such a bell shape. Such bell-shaped portions
of stiffeners 25 overcome the counterforce of the elastomeric
material of wall 18 of sleeve 10 to form bell shape 27.
Referring to FIGS. 2-3, the medial region 12 of snake sleeve 10 is
configured with one or more longitudinal slits 28 that extend
through wall 18 between stiffeners 25 into lumen 20. The proximal
end 11 of snake sleeve 10 is provided with a conventional
elastomeric seal or gasket 29 (see FIGS. 1-2).
A constraining sleeve 30 is provided to constrain the bell shape 27
of snake sleeve 10 so that it can be introduced through a cannula.
Referring to FIGS. 1-2, constraining sleeve 30 is made of a
thin-wall plastic material with a distal end 31 that exhibits a
slightly reduced diameter opening to prevent the constraining
sleeve from slipping easily in a proximal direction over snake
sleeve 10. Referring to FIGS. 6-7, distal end 31 of sleeve 30 has a
plurality of weakened-plane longitudinal indentations 32 that will
split the distal end of constraining sleeve 30 when it is slid
proximally relative to sleeve 10 under force. The proximal end of
constraining sleeve 30 has flange 33 for reasons explained
hereinbelow.
Operation and use of the instrument of FIGS. 1-2 in performing a
method in accordance with the present invention can be described
briefly as follows. Assume that the surgeon wishes to remove
excised tissue, for example a lymph node, from an endoscopic
workspace overlain by the abdominal wall. Assume a 10 mm. diameter
cannula is available within the abdominal wall for tissue removal.
An endoscope is disposed in another cannula (not shown).
Referring to FIGS. 8A-8H, the abdominal wall has layers of skin 41,
tunica adiposa (fat) 42, fascia 44, muscles 45 and peritoneum 49.
Referring to FIG. 8A, cannula assembly 50 has longitudinal bore 51.
Excised tissue 55 is to be removed from insufflated workspace
56.
Referring to FIG. 8B, snake 5 is provided from the manufacturer
with constraining sleeve 30 in its distalmost position so as to
constrain bell shape 27 of snake sleeve 10 (see FIG. 1). The
surgeon then introduces snake 5 through cannula bore 51 until
flange 33 abuts the proximal end of cannula assembly 50. The
spacing of flange 33 relative to snake sleeve 10 provides that bell
shape 27 of the snake sleeve is distal (inward) from the distal end
of the cannula when flange 33 abuts cannula assembly 50.
Referring now to FIG. 8C, the surgeon with one hand (phantom view)
holds snake 5 and with the other hand introduces tissue-grasping
instrument 60 through gasket 29 and snake lumen 20 into insufflated
workspace 56. Instrument 60 is shown with basket-type snare 61
similar to Olympus Model FG-16L-51635, although any type of
endoscopic retrieval forceps is suitable.
As also shown in FIG. 8C, the surgeon then pulls proximally
(outward) on cannula assembly 50 and removes it from the incision.
The proximal movement of cannula 50 also causes constraining sleeve
30 to move proximally as flange 33 abuts the cannula. The proximal
movement of sleeve 30 thus allows bell shape 27 to expand within
workspace 56. As shown in FIG. 8C, the surgeon leaves the cannula
generally fitted around proximal end 11 of snake sleeve 10.
Alternatively, the surgeon may entirely remove the cannula from its
sliding fit over snake 5 and set it aside. It also should be noted
that the steps shown in FIGS. 8B and 8C may be reversed with the
surgeon first introducing grasping instrument 60 into snake lumen
20 and then sliding the assembly through cannula 50.
Referring to FIG. 8D, the surgeon then recovers tissue 55 in snare
61 under endoscopic vision, utilizing another accessory instrument
in another cannula (not shown) if necessary. FIG. 8D depicts tissue
55 in snare 61 being pulled through bell shape 27 which causes the
distal end 14 of the snake sleeve 20 to expand radially.
In FIG. 8E, tissue 55 is shown as it is pulled through the
abdominal wall which causes snake lumen 20 to expand in transverse
dimension, in turn causing muscle layer 45, fascia 44 and fat layer
42 to be displaced radially outward from axis 16 of the snake. The
resilience of tissue layers in the abdominal wall allows excised
tissue 55 to pass therethrough without tearing tissue layers or
significantly enlarging the dimensions of the incision.
In FIGS. 8F-8G, excised tissue 55 is outside the abdominal wall
still in lumen 20. The surgeon or his assistant then may pull
tissue 55 through slit 28 in wall 18 with forceps 65. Note that in
FIG. 8G, a portion of medial region 12 of snake sleeve 20 may be
configured with a thin wall portion 66 including a cooperating
pattern of slits 28 such that sleeve 10 will collapse under the
pressures of the abdominal wall thereby preventing substantial
leakage of insufflation gases from the workspace when instrument 60
is not within lumen 20. Snake sleeve 10 then may be reintroduced
into workspace 56 to remove other tissue in a like manner. As shown
in FIG. 8H, upon completion of the tissue removal procedure,
cannula 50 then easily may be slid distally (inward) into its
original position in the abdominal wall with snake sleeve 10
serving as a guide through the incision. Thereafter, snake 5 and
accessory instrument 60 may be withdrawn leaving cannula 50 in
place.
The above-described snake 5 utilizes a single sleeve 10 wherein
excised tissue 55 is recovered and pulled through snake lumen 20
with a grasping instrument. In some situations, it may be difficult
to grasp tissue 55 or to maintain a grip on the tissue as it is
pulled through snake lumen 20. For this reason, FIGS. 9-10 depict
an alternative embodiment of snake 105 with dual sleeves.
Alternative snake sleeve 110 with proximal and distal ends 111 and
114 is similar to the embodiment previously described having wall
118 made of elastomeric material and having lumen 120 along with
stiffening elements 125 (see FIG. 10).
Snake device 105, however, includes a separate tissue-recovery
sleeve 130 adapted for pulling tissue through lumen 120. Referring
to FIG. 10, recovery sleeve 130 with proximal end 131 has
longitudinal tissue-recovery passageway 132 extending therethrough
which is dimensioned to receive an accessory grasping instrument as
well as tissue 55. The proximal end 131 of sleeve 130 has a
conventional elastomeric gasket 133. The distal region 134 of
sleeve 130 and passageway 132 are capable of expanding in
transverse dimension to accommodate excised tissue similar as
previously-described. Longitudinal stiffeners 135 incorporated into
wall 138 of sleeve 130 induce bell shape 139 into the distal end of
the recovery sleeve. As can be seen in FIGS. 9-10, the distal end
of recovery sleeve 130 can be withdrawn into snake sleeve 110 thus
constraining bell shape 139 for introduction of snake 105 through a
cannula.
Of particular interest to dual sleeve snake 105 is that excised
tissue 55 will not itself cause friction with inner surface 140 of
snake lumen 120 as the tissue is pulled through the lumen. In dual
sleeve snake 105, the sliding interface between snake sleeve 120
and recovery sleeve 130 is inner surface 140 of lumen 120 in
contact with outer surface 142 of recovery sleeve 130. Friction
between surfaces 140 and 142 can be reduced by using "slippery"
materials for the respective surfaces, for example slippery
elastomeric materials. Alternatively, stiffeners 125 and 135 may be
partly or wholly exposed in the respective surfaces of the sleeves
and such stiffeners may be fabricated from slippery materials such
as Teflon.
Operation and use of the instrument of FIGS. 9-10 in performing the
method of the invention can be described briefly as follows.
Referring to FIG. 11A, assume again that the surgeon wishes to
remove excised tissue 55 from a workspace overlain by the abdominal
wall. Referring to FIG. 11B, the surgeon introduces snake 105
through cannula bore 51. An indicator mark 144 on snake sleeve 110
indicates when the distal end of sleeve 110 is distal (inward) from
the distal end of the cannula.
Referring now to FIG. 11C, the surgeon with one hand (phantom view)
slides the cannula proximally (outward) over the snake device 105
and sets it aside. The surgeon then introduces grasping instrument
150 through gasket 133 and passageway 132 in recovery sleeve 130
into insufflated workspace 56. It should be noted that the steps
shown in FIGS. 11B and 11C may be reversed with the surgeon first
introducing instrument 150 into snake 105 and then sliding the
assembly through cannula 50.
Under endoscopic vision as shown in FIGS. 11C-11D, the surgeon
grasps tissue 55 and pulls it proximally (outward) into bell shape
139 and passageway 132 of sleeve 130. In FIG. 11E, the tissue is
being pulled through the abdominal wall which displaces radially
outwardly portions of walls 18 and 118 of sleeves 120 and 130,
respectively, as well as muscle layer 45, fascia 44 and fat layer
42. As shown in FIGS. 11F-11G, it is preferable to withdraw grasper
150 after tissue 55 is within bell shape 139 of recovery sleeve
130. Thereafter, the surgeon may simply grip and pull on proximal
end 131 of recovery sleeve 130 to pull the tissue through snake
sleeve 110.
After recovery sleeve 130 is fully withdrawn proximally from snake
sleeve 110 as shown in FIG. 11H, the cannula 50 may be slid
distally (inward) over snake sleeve 110 back into the incision
using snake sleeve 110 as a guide. It should be noted in FIG. 11H
that the surgeon may use his thumb and fingers to collapse snake
sleeve 110 to prevent insufflation gases from escaping from
workspace 56 through snake lumen 130. Alternatively, the proximal
end of snake sleeve may be fitted with a conventional elastomeric
gasket (not shown).
It can be seen that the snake sleeves, 10 and 110, in the
above-described embodiments are similar. Other embodiments of
expandable snake sleeves incorporating additional features are
illustrated in FIGS. 12-15 and such features are suitable for
either single-sleeve or dual-sleeve snakes.
Referring to FIGS. 12A-12B, additional structure may be provided
for making a snake sleeve 200 with an enhanced ability to expand in
the transverse dimension. Such enhanced expansion ability assists
in displacing abdominal wall tissue radially outward to accomplish
the manner of operation of a snake sleeve. FIGS. 12A-12B depict
stiffening elements 205 disposed helically around wall 208 of snake
sleeve 200. As tissue is pulled through lumen 210, the helical
stiffening elements, depending on their spiral lead dimension 211,
will tend to move somewhat helically in expanding radially outward
as tissue is pulled though the lumen. In other words, axial forces
on tissue in lumen 210 will be transformed partly into helical
forces (radial and angular) within wall 208 that in turn displace
abdominal wall tissue layers radially outward in an efficient
manner. A similar snake sleeve (not shown) may have cooperating
right-hand and left-hand helical elements.
Referring to FIG. 12A, structure is provided for allowing snake
sleeve 200 to grip the abdominal tissue surrounding the sleeve. The
purpose of a snake sleeve gripping surrounding tissue is to insure
that the surgeon does not have to apply distal counterforce on the
snake sleeve as proximal force is applied to pull tissue through
the snake lumen. For example, exterior surface 212 of sleeve 200
may have gripping ribs 215 molded into the material of wall 208 to
prevent it from sliding proximally in tissue. Alternatively, the
elastomeric material in wall 208 may be a somewhat "sticky"
material that resists sliding through the tissue of the abdominal
wall.
Referring to FIGS. 13-14, interwoven snake sleeve 220 has helical
stiffening elements made e.g. of thin flat plastic that are loosely
interwoven in opposing right-hand spirals 222a and left-hand
spirals 222b. Thus, withdrawal of tissue through such interwoven
sleeve 220 causes lumen 225 to increase the transverse dimension as
both helical elements counter-rotate relative to one another thus
effectively changing the spiral lead 229 of the elements, wherein
the spiral lead is defined as the axial dimension required for a
helical element to wrap 360.degree. around sleeve 220. In such an
interwoven sleeve 220, the helical elements alone may make up a
suitable snake sleeve in which case the elastomeric sleeve 230
depicted in phantom view is optional (see FIGS. 13-14).
FIG. 15 illustrates a dual-sleeve snake 235 with snake sleeve 240
having its distal end slidably disposed distally (outward) from
tissue-recovery sleeve 245. Structure is provided for making
recovery sleeve 245 slide with reduced resistance through snake
lumen 250. Recovery sleeve 245 is formed of a plurality of
right-hand and left-hand helical elements, 251a and 251b, that are
made of thin strips of slippery material such as Teflon that slides
easily within snake lumen 250. In the distal portion of sleeve 245,
the helical elements are resiliently formed in bell shape 252 in a
state of repose. The distal portion of the sleeve is capable of
both expanding and contracting in transverse sectional dimension as
spiral lead 253a changes (see phantom views in FIG. 15).
Still referring to FIG. 15, the dual-sleeve snake 235 also includes
structure incorporated into recovery sleeve 245 for gripping and
compressing excised tissue 55 inwardly toward axis 254. The purpose
of gripping the tissue is to insure that when tissue 55 is first
pulled into the passageway 255 with a grasper, the grasper may be
removed and the tissue will not move distally out of passageway 255
when recovery sleeve 245 is pulled proximally. The purpose of
compressing tissue 55 in the cross-sectional dimension is to make
it easier to pull the tissue through lumen 250 in snake sleeve 240.
In other words, the snake sleeve will require less expansion to
accommodate the lesser cross section of tissue 55, in turn
requiring less displacement of tissue in the abdominal wall. Thus,
pulling proximally on proximal end 256 of recovery sleeve 245 will
cause interwoven sleeve 245 to reduce its transverse sectional
dimension whereby passageway 255 will both grip and compress
excised tissue 55 as it is pulled into snake lumen 250. In this
embodiment, wall 258 snake sleeve 240 may be fabricated of a more
rigid elastomeric material than previously described to assist the
recovery sleeve 245 in compressing tissue.
Of particular interest to the present invention is that
tissue-compressing recovery sleeve 245 of FIG. 15 may be utilized
alone to remove certain soft or malleable tissues through a rigid
cannula assembly. Referring to FIGS. 16A-16B, operation and use of
only recovery sleeve 245 alone in performing a method in accordance
with the invention can be described briefly as follows. Referring
to FIG. 16A, assume again that the surgeon wishes to remove excised
tissue 55 from a workspace overlain by the abdominal wall. FIG. 16A
depicts the surgeon introducing recovery sleeve 245 through cannula
assembly 50 into workspace 56 (the constraining sleeve not shown).
Grasping instrument 260 is introduced through tissue-recovery
passageway 255 in recovery sleeve 245 to grasp tissue 55. As the
tissue is pulled into the distal bell shape 252 of sleeve 245, the
sleeve and passageway 255 naturally expand in transverse dimension
to decrease spiral lead 253b of elements 251a and 251b until
passageway 255 has a large enough transverse dimension to
accommodate tissue 55 (see phantom view in FIG. 16A). After tissue
55 is disposed within passageway 255, the grasping instrument 260
is withdrawn. Thereafter, as shown in FIG. 16B, recovery sleeve 245
is pulled through bore 51 in cannula 50. As sleeve 245 is pulled
proximally, the helically interwoven sleeve first grips tissue 55
and thereafter compresses the soft tissue as it is drawn into the
cannula. The proximal sliding of sleeve 245 into cannula 50 causes
the interwoven elements to interact so as to lengthen spiral lead
253c of helical elements 251a and 251b as the transverse sectional
dimension of sleeve 245 is constrained by the reduced dimension of
bore 51 of the cannula. In so doing, the helical interaction of
elements 251a and 251b stretches tissue 55 axially since the
helical elements frictionally engage tissue 55 within passageway
255. Such stretching of tissue 55 serves to reduce the
cross-sectional dimension along with compressing the tissue to make
it easier to pull the tissue through the rigid cannula. Another
grasper (not shown) may be introduced through another cannula to
pull distally on the distal end of helical elements 251a and 251b
which will further compress tissue 55 within passageway 255 as
recovery sleeve 245 is pulled through the rigid cannula.
Although the instrument and method of the present invention has
been described for removing excised tissue from an insufflated
workspace through the abdominal wall, the invention may be used in
conjunction with tissue removal from any location in the body in
which a cannula is disposed, whether or not the space is
insufflated. This disclosure is illustrative and not limiting;
further variations will be apparent to one skilled in the art in
light of this disclosure and are intended to fall within the scope
of the appended claims.
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